lhirFanla.

in prezent bste medic Mirei I I e Mandelbrojt-sweeney

i+ -k1ps's2eni
esre meotc rezident
Eileen Sweeney
Anfureza pentru medicigi asr.s-

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Prefaii de ]ean Bernard
Traducere de Emanuela Stoleriu

oi-*eerey, Eileen Sueeney; trad.:

POLIROM
20r4
 .\.a,!.&4.

Contents/Cuprins
Prefa1d....... ..........., 13
Cuvdnt-tnainte la edilia apatra .................. 15
Cuvdnt-tnainte la edilia atreia .................. 16
Cuvdnt-tnainte la edilia tntki........... ........... 17
Introducere ...........19

generale....
General expressrbns/Expresii ...................2t
MiscellaneouslGeneralittrli .....................21
TimelBxpresii legate de timp.......
Days of the weeklZilele sdptdmdnii .........22
Months of the yearlLunile anului ,.....,.....23
NumberslNtmere .......... .,,".23
QuantitylCantitate........,.. .,..................23
Length and distancellungime Ei distanli ...,........:......24
WeightlGreutate ............ ....;............ .....24
TemperaturelTemperaturl .....................24
Pacient historylAnamneza pacientului .......... .............27
MiscellaneouslGenera1it51i................ .....27
General healthlStarea generaltr ..............2'l
Past medical historyllstoricul personal ......................28
Drug historylTratamente unnate ............28
Family historyllstoricul familial ;............29
HabitslObiceiuri ............ ......,.............. 30
Social historylMediul de viald ...............30
The elderlylPersoanele in vdrstd .............31
Review of systemsl Anamneza referitoare la sisteme............... j. ......32
PainlDurerea............... ....,.., 35
HistorylAnarrtneza........... ................:..... 35
Cardiovascular systemlSistemul cardiovascular.....,....... ..,............ 39
HistorylAnamneza .............39
Chest painlDurerile toracice....... ......39
Ischaemic heart diseaselCardiopatia ischemicd ....,..41
DyspnoealDispneea....... .................. 42
 -'i*dbbs.

Ankle oedemaiEdemul gleznelor .......

PalpitarionslpalpitatriiIe.....,.............. """"""','.' 42
Heart failurellniuficienla .urOiu.e.....' """"""""' 43
peripherat vascutar
svmptomstieil; tu;qi";;i;;;;;;i;;; ..:.:.,........:.
Thromboembolic diseaselBoala tromboembolicd.... .....".1:
Common cardiac conditionsl Afecgiuni cardiace
.....,.,........,.,46
clinical examination and reportiig
frecvente.....,......... 4j
findingsllxamenur clinic ai datele obginute
la examenul clinic..,''...'
,....,'.'......',.,...i48
Arterial pulseslpulsul arterial ....... ........ .
Hean soundslZgomotele cardiace
Murmursliluiurile.............. .. ..,...... ' ' """""""""' 50
I nv e s t i g a t i o nsl t nve stig a l ii
Bliod tes*lAnaliza iAngel"i.....,,....,.. """""""""51
Etectrogardiosiam (ECG)tEtectro..raioer"*.
^. ieic)nccj :::.,.:.::...,::......:.:;i
PharmacologylFarmacologie ..,..........,
Anticaagulanls/Anticoagulante.,....,... .,..,......,......... 54
..,.....,....,,,..54
Symptoms/simptome
sp i rato ry syste m /p n e u m o I og y r
lg
Sistemul respirator/pneumotogiL ..,......,... ss
HistorylAnamneza,.......... ........,........... 55
coughlrusea..!..!..!!;....... .,........,...... 55
SputumlSputa...,....,....... ......,.......... 55
H ae mop ty s i s/Hernoptizia
Chest painlDurerile toracice...........,..-""-""' "''"' 56

Occupational historyllstoricul profesio.;i..:..............................................

Smoking historyllstoricul de fumtrtor.,..... ;i
.............57
Asthmal Astmul...............
"""""" 58
'ol,rrrit:"| iri*;r";;;;;"iti
copD (chronic
BPOC(bronhopneumopatiaobstructivlcronicl)
- .............!;........59
/ysrn therapyloxigenorerapia
Modified
.............60
Medical Research Council (MMRC) Dyspnoea Scalel
Scala de dispnee conform Medical Research
Co'un.iL iprrvr{Ci ....... 60
C:yyor: respiratory conditions/Afecliuni respiratorii frecvente..........................61
clinical examination and findingsrExamenur itinic gi datele
obginute
la examenul clinic '........
....,.................62
InspectionlExaminarea.... .................62
Palpationlpalparea .........
Peicussionlpircu1ia............................
"""""""':" """"""'62
AuscultarlonlAuscultalia..............
_ character of vocat resonance/Mooificarea re;;;;;;;;;";ii.......................... :;
I nve s t i g at i onsll nve stigalii
Examination of the sp.wtumlExarnenul ,p;r;i..............................................:;
Blood testslAnaliza sAngelui...........,..:...
Examination of the pleuralExaminarea pleurei
. .................65
................... . ..........65
Intradermal tests/lntradermoreactrii......... .
. ......................65
 Pulmonary function tests (PFT)lProbe functrionale respiratorii.,..................,. 65
RadiologylExamenul radiologic.... .....66
Gaslroinfes ti n al sy ste m /g a stro e nte rol og y I
digestiv/gastroenterologie,,,...,.......
Sistemul ........,....67
HistorylAnamneza........ .....67
Abdominal painlDurerca abdominal[ .,..,..,.......,....67
Appetitel Apetitul ......,.,.. ....,..........,. 69
WeightlGreutatea ......,.... .....,...,,,,...., 69
Earty satiation and postprandial fullncsslSa6ietatea precoce gi
plenitudinea postprandial[ '.... ' " '. 69
voma
Nausea and vomiting (N&V)lGreaIa gi '....'..' 70
HaematemesislHematemeza,,.,...,....". ..............'... 70
Gastro-oesophageal reflux disease (COKD)lRefluxul gastroesofagian (RCE).'. 70
SwallowinglDeglutilia...,., ,........ '..... '.. '.71
Bowel habitlTranzitul intestinal .,..'.'...'.72
Abdominal distensionlDistensia abdominald ',.."74
Rectal bleedinglSdngerlrile rectale '.......'.".."..'." 74
Jaund.icellcteru1.....,...... .......... '. '...., 75
Gastrointestinal cottditionslBoli gastrointestinale ,... '.. '.. '.. 76
''
5"5 Clinical examinationlExamenul clinic....,".,. '...'."'.....71
55 InspectionlBxaminarea.... .'............'..77
55 PalpationlPalparea .....,... '. '. '..... '. '. 79
. ''
56 PercussionlPercutia ......... .. '... ',....... ' 80
'
56 AuscultationlAuscultalia. ........:'.'.......'..'..."......'...81
57 Digital rectal examination (DRE)lTugeul rectal (TR) ...'.....'....'..81
57 Investigationsllnvestigalii ...........'...'. '.....81
Alimentary tractlTubul digestiv .........'81
LiverlFicatul ..".........." 83
Gallbladde r, bile ducts and pancreaslVezic(ul)a biliar5,
cdile biliare qi pancreasuI................ "...'....'.'....".83
E ndocri ne syste m/e ndocri n olog yl
Sistemulendocrin/endocrinologie ....'.'.....8s
Diabetes metlituslDiabetul zaharat ..'.......'..'..85
HistorylAnamneza ..'..'.85
Tlryroid glandlGlanda tiroidd...... .'....'...'..87
llisle,rylAnamneza ...'....87
Ctinical examinationlExamenul clinic ......... ...... '... '. ' 90
..........63 Investigatiortsllnvestigalii .. '....... '.......91

lonarller !'oclr........... ............. ". 64 Other endocrine cond.itionslAlte boli endocrine...............' ........'.'.'91
......,......65 Hypothalamus-pituita.ry axlslAxul hipotalamo-hipofizar..'... "'.....91
Tlryroid glandlGlanda tiroidd ..."........91
. ',,. '. '... '. 65
......... 65 Parathyroid glandslGlandele paratiroide ............... ...... .. '.. ',.:....91
r"............... .........65 PancreaslPancreasul ...........91
............. 65 Adrenal glarzdlGlanda suprarenal5 ......'................92
Investigationsllnvestigalii ..... ................ 92
 G en ito-u ri n a ry syste m/ne p h rot og y/u rot y/
og
Sistemulgenito-urinarlnefrologiJiurorogil ......,........... e5
History/Anamne2a...........
Flank painlDurerea laterall/in flanc .......... ....... 95
Micturition clutltsel after ..........95
painlModificrri urinare oufe criza dureroasr..,.
the
M_odification of urinelModificdri ale 96
urinei......... .:., ...........,........,.,.. 92
HaematurialHematuria ...................,.gj
Proswte p roble ms /probleme ale prostatei...
...
Incontinencellncontinen1a.............. ...
common urinary ffact conditionslAfecliuni ......,.,........ 99
frecvente ate apuratutui urinar ..,...... gg
of the male genitarialdxamenul aparatului genital
-- .Examination
Urinary system investigatiortslExamenul aparatului
masculin.......l00
Urine testl Analiza urinei
urinar..]..... "... 100
sdngel"i....,........
Blood testslAnaliza """""""'.. 100
RadiologylExamenul radiologic........ .....................................................
-
DialysislDiali2a............. ,tll
....................................... ..... tVz
Nervous system/ne u rotogyl
Sistemulnervos/neurotogie..........
:................,..........103
HistorylAnamneza"""'.'.. ................... 103
HeadachelDureri de cap/cefalee..
Motor disturbanceslTulburlri motorii .....103
.................106
Balance disturbance lTulbur5ri de echilibru
Neurological conditionsl Afecliuni neurologice.
. ... .. ltO
Clinical examinationlExamenul clinic......... ............. ll2
Mental statelstarea mentald....... ...... ilz
Cranial ne rve s /N ervii cranieni
nene functionlFunclia n".uurui *oi;;.....,........................,......,.....
lotor li3
Tone ofmuscleslTonusul rnuscular..,.. ..!.....!..;....................... lt6
Tendon reflexeslReflexele osteotendinoase.....
Neck stffiesslRedoarea cefei .,..... 116
Sensation/sensibilitatea... ........... 116
................. lt6
Neurological examinationlExamenul neurologic...
.,................. ll7
Investigationsllnvestigalii ...............,...,. ll9
Obsfefrlcs and gynaecologylObstetrici gi ginecologie
.................121
HistorylAnamneza ............ r2r
MenstruationlMenstrualia ...............
Abnormal vaginat bleedinglSAngerarea vaginall l2l
anormall...,. ....122
dischargelscurgerile vaglnate
lySi1at ............,....122
Vaginal prurituslprurirul vaginai
Preconceptionlinaintea conceptriei... ......t23
. PregnancylSarcina ....................123
Past pregnancieslSarcini precedente...
.......123
Prolapse lprolapsul .........
...........,.....t24
Birth controlliontraceptria """""""'125
................... 126
 Infertilityllnfertilitatea .....;.....,......,.;127
MenopauselMenopau2a................ ..r..............,.,.128
,........95 Clinicat exqminationlExamenul clinic......... .............128
Investigationsllnvestigalii ..........,.......... 129

l3l
HistorylAnamneza........... ..... 131

Breast lumpllJmfldturi la nivelul sAnilor...,.. ...............:..........131

Mastalgia (breast pain)lMastalgia (durerea de sdn) ................. 132
Breast examinationlExaminarea sinilor ....132
Common breast conditionsl Afecliuni frecvente ale sdnilor... .. .. ".. .132. ..

Breast surgery l Chirurgia sAnilor

PaediatricsiPediatrie .... ,......................... 135
HistorylAnamneza........ .....135
MiscellaneouslGeneraIittr1i.,.............. ................135
Pregnancy historyllstoricul sarcinii..:..........,..... ............,.......135
Neonatal periodlPerioada neonatald............... ..............136
Feeding lrisrorylModul de alimenta1ie............... ........'...'........137
ImmunisationslVaccindri ."'....'....'.".137
..'. '.. ' '.. 103 Developmental milestones lDezvoltarea psihomotorie
Social historylMediul de vialX ..............'.'..'......'139
Chitdhood dlse as e s lBolile copiltrriei
PsychiatrylPsihiatrie...... ......' l4l
History l Anamneza........
Mood disurbancelTulburflri de dispozitie...........'.' ..'..."........ t4l
Thought contentlcanlinutul gdndurilor........... .....143
Common psychiatric conditionslBoli psihiatrice frecvente .................;....'........143
InteltectuatfunctionslFuncliile intelectuale............. ...,.'....".'......144
TreatmentlTratament .'....'.'..."'... ....144
Toxicomania and addiaion (alcohol)lToxicomania Ei dependenla (alcool) .....".'.1'15
I nfe ctiou s dlseasesiBoli i nfectioase
History l Anamneza ...........
The febrile patientlBolnavulfebril .'-.147
List of infectious diseasesllista bolilor infectioase "'..149
Clinicat examinationlExamenul clinic .....,... ........ '. ' '. 150
Investigationsllnvestigalii .
". 150
Sexually transmitted infectioru (SI/)/Boli cu transmitere sexual[ (BTS)........"'.' l5l
MalarialMalarialPaludismul.............. ..'.....'.."..'.....152
Tuberculosis (I8)/Tuberculoza (TBC).. ......'...'.......'.153
TB presentationslForme de tuberculozd.............. .'.....'.'.....'.;'153
Investigations ofTBllnvestigalii pentru depistarea tuberculozei'....'..'.'......."153
H o spital a c qui re d / no s o c omia I infe c tions I
Infeclii contractate in spital/nosocomiale....... ........"'154
Infection control in health carelControlul infecliilor in serviciile de sdndtate ...15+
 HaematologylHematologie ........,.........,..155
HistorylAnamneza........,.. ...................155
MiscellaneouslGeneralitdti ................
................ 155
Transfusions of blood protructsrTransfuzie de componente
-- sangvine ............. i;;
Haematological conditionrlBoli hematologice ..,...,.........., ...,....... 157
I nve s ti g ationsllnvestigagii
Futl btood count (FBC)/Numdrarea f";;i;;';;;g"i". iNei):,.......:............ ffi
Coagulationl Coagularea.. .............:,................... ................ i5;
Other testsl Alte teste.......
t"
Haematotogy and oncotogy terminotogytr;;i;;i";t; firi;;il;" ;.;;;;i;;i; '
gioncologie, ..,.................159
Vascular accessl Acces vascular..........

-r'';f,;,nffi,:t;ffiil;1;1;;;'"1
TraumatologylTraumatologie .............
,,, i. ., ... l;1
Rheumatotogic1t conauiorslBoli .rurnuti""......:...:.....:.....:...:...:'.....:...:...:..:...
Clinical examinationlExamenul clinic.........
l:;
.............167
Inspe cti on lExaminarea... .
paipationtparparea ......... :...::...,:..:..:.:.....:.:.................:...:.:. i:;
M ove me nt s / Mo bi l itatea
spine or vertebral corumn exarninationlExamenul coloanei vertebrale
............... 16g
Investigationsllnvestigalii ..................... i;;
Blood testslAnalize de sdnge.......... ....................168
J_oint aspiration/puncgia articulard ... ......................:.,:......i;;
Rad.iologylExamenul radiologic
........169
Other investigationslAlte investigatrii... ................169
PharmacologylFarmacologir.............,. .."............ 169
Non.pharmacological treatmentslTratamente nefarmacologice .......
"............. 170
DermatologylDermatologie .............. ....... r73
HistorylAnam\e2a........... ...................173
, RashlErup1ia.......... .....,.............. izi
common deimatotogicat disordersteori oermar;i;;;;; ;;;;;;;.................,....
176
Past medical historyllstoricul medical.
.. ... ............ izo
Corymon dennatological disorders/Bolidermatologice frecvente
....1:16
Malignant melanoma/Melanomul malign .......,.....177
Clinical examinationlExamenul clinic.......... ....,.,.....177
Clinical findings (of the lesion)llnformaliile oblinute
la examenul clinic (al leziunii)......
........177
I nv ti at onslInvestigalii
es g i
Medications/Medicamente................ .....t79
Medical recordslFiga de observafie..............
181
M is c e llane ouslFiga administrativ[
l8l
Medical recordstObservalii medical.........:...............::................^................
181
False friendslFalgi
r83
 List of symptoms, syndromes and diseases/
Lista simptomelor, iindroamelor gi bolilor... ................ r85

List of abbrevi ations/Lista abrevierilor.

Health care personnel and establishmentsl

Personalul medico-sanitar gi unititile de ingrijire.............. ...........22t
Health care stafflPersonalul medico-sanitar.............. ..................221
Specialists (consuhants)/Medici specialigti.... ............221
alternativd... ........223
Alternative therapistslSpecialigti in medicind
Couns ellors lConsilieri ..,....'...........
Nursing stafflCadre medicale medii.........!........!...r... j ...........223
Paramedical stafflPersonalul paramedical ............ ..................,224
Multidisciplinary team (MDT)lEchipa multidisciplinar[.......... ....................224
WelfarestafflPersonaluldincadrulserviciilorsociale......'.
Administation s/a,;f/Personalul administrativ ............. ............,.224
Health care facilitieslUnit[1i de ingrijire ...................225
In general practicelLaclinicl .......,..225
At the surgery, at the health centelLa clinica de chirurgie,
la centrul de ingrijire a strn[t[tii.... ........;............225
At the chemisrlpharmacy/La farmacie. .................226
At the communiry health service centerlLa dispensar ...............226
At the hospital/La spital
FacilitieslUnitdti..........., ................226.
spitalului..
Hospital wardslSecliile ....227

Working abroadlProfesarea in striinitate:. ...............229

GP training in Great Brttain and lrelandlFormarea medicului specialist
in medicinl intern5 in Marea Britanie gi Irlanda.... ...............;......229
Specialist training in Great Britain and lrelandlPractica medicului specialist
in Marea Britanie gi Irlanda
adrese
Address booklCarnet de ........,,....230
CollegeslColegii............ ..............,.,230
M edical D efens e Organis ationslOrganizalii de asigurare
medicali
de rlspundere ...................231
PublicationslPublica1ii... ..........,.....:.232
OtherlAltele ............ .........:........ ..........,..........232
Curriculum vitaelCurriculum vitae .....................232
,''..'.'....,,.'...,. 177 PharmacologylFarmacologie.......... ........235
HistorylAnamneza........ ....235

...,:,179
Allergiesl{lergii............. ....................235
FormlFormd ....................236
PresuiptionlRegeta ....".., ....236
181 Side ffictslEfecte secund&r€..........:.. ...,.................237
l8r
181 Index - limba eng1e2d............... ...............243
Irulex - limba romhnd............... ...............249
 General expressions Expresii generale
Miscellaneous Generaliti'ti
Hello, what is your name? Buntr ziua, cum vtr numili? :

- Surname - Nume de familie

- First name - Prenume
How old are you ? Ce vArsti aveli ?

Where do you feel the pain ? (show me Unde vI doare ? (ardtatri-mi cu mdna)
with your hand)
Point out in the table of contents the chap- Indicatri in cuprins capitolul referitor la
ter related to your complaint. problema dumneavoastr5.

Time Expresii legate de timp

Seconds (sec) Secunde (sec.)
Minutes (min) Minute (min.)
Hours (h/hr) Ore (h)
Days Zile
Weeks Strpttrmini
Months Luni
Years Ani
For abbreviations for days, weeks and Pentru abrevierile referitoare la numtrrul
months as they are used in English med- dezile, slpttrmdni, luni in fi$ele de obser-
ical records, see table 1. vade englezeqti, vezi tabelul l.
Table l/Tabelul I
Expressions of days, weeks, months in the medical recorcl/
Exprimarea zilelor sdptdmdnilor 1i lunilor in fiSa de observa[ie

#t7 3t7 #t52 2ts2 #t12 6t12

Number of Three days Number of Two weeks Number of Six months
davs weeks months
Numfru] de Trei zile NumXrul de Dou[ Numirul de $ase luni
zile s[ottrmAni slntlmAni luni
22 General expressions

Next Urmitor (urmdtoare)

Last Ultimul (ultima)
Before inainte
After Dupd
Today Azi
Tomorrow Mdine
Yesterday Ieri
Day before yesterday Alaltdieri
Morning Dimineatra
Afternoon Dup5-amiaza
Midday I-a prdnz
Night Noaptea
Occasionally Din cdnd in cdnd
Rarely Rar'
Often Adesea
During in timpul
Always intotdeauna
For De...
I have a pain for three months. Am o durere de trei luni.
Since (a date) De... (incepdnd de Ia o anumit[ dat[)
Since when do you have this pain ? De cAnd avetri aceastd durere ?
I have a pain since yesterday. Arn o durere de ieri.

Days of the week Zilele siptimAnii

Monday Luni
Tuesday Ma4i
Wednesday Miercuri
Thursday Joi
Friday Vineri
Saturday SAmb[ttr
Sunday Duminictr
 Expresii generale
{tor (urmtrtoare)
nut (ultima)
Months of the year Lunile anului
me January Ianuarie
l Rbruary Februarie
March Martie
r April Aprilie
May Mai
Eturi June Iunie
imga July Iulie
f-amiaza August August
rinz September Septembrie
pa October Octombrie
cfod in cdnd November Noiembrie
December Decembrie
El
ryul
deauna Numbers Numere
o durere de trei luni. One Unu
- (ircepand de la o anumit[ datl) Two Doi
:fod avegi aceaste durere ? :
Three Trei
o &uere de ieri. Four Patru
Five Cinci
Six $ase

Zilele slptimAnii Seven $apte

Eight opt
Nine Noutr
r len Tnce
curi

ri Quantity Cantitate
ru
rfficl Tea spoon Lingurild
Table spoon Lingurd
Cup tull Cantr
Millilitres (ml) Mililitri (ml)
Litres (l) Litri (l)
Pint (- 474 ml) Pintd
 24 General expressions

Noral amount Cantitate normall

Small amount Cantitate mictr/Putrin
None at all Deloc
A lot Mult, dbundent
Reduced quantiry (a few drops) Cantitate foarte micd (cdteva picdtqri)
I unit of alcohol o unitate de alcool
(alclvol X volume consumed) : 1000 : (alc/vol x volum consumat) : 1000
X units X unitdli

Length and distance Lungime gi distan{a

Millimetre (mm) Milimetru (mm)
Centimetre (cm) Centimetru (cm)
Metre (m) Metru (m)
Units of measurements sometimes still Unitdti de m5surX incd utilizate ln
used in English-speaking countries :
trdrile anglofone:
* Inch (= 2.54 cm) - Inch
- Foot (= 0.3048 m) - Picior
- Yard (= 0.9144 m) - Yard

Weight Greutate
Gram (g) Gram (g)
Kilogram (kg) (l kg = 2.2 tb) Kilogram (kg)
Units of measurements sometimes still Unidti de mtrsurI incl urilizate in
used in English-speaking countries :
15rile anglofone:
Pounds (l lb : 0.45 kg) - Livre
Stone (14 lbs) - cca6kg

Temperature Temperaturi
Celsius ('C) Grad Celsius ('C)
Now used in most countries except in in prezent folosit in majoritatea gri-
the USA and in the English-speaking lor, cu exceptia Statelor Unite Si a
elderly population ! persoanelor anglofone in vArstd !
Fahrenheit ("F) grad Fahrenheit ('F)
 Expresii generale 25

Celsius to Fahrenheit: Transformarea grade Fahrenheit -

frrrc normal[ "F=(oCx9lS)+32 grade Celsius : oC : ("F - 32) x 5/9
ftete micilPulin - Iluman body temperature - Temperatura corpului uman
rc 36.1 - 37.5 .C (96.9 - 99.5 'F) 36,1-37,5 oC
t, ibundent
flrte foarte mici (citeva pic[turi) Table 2/Tabelul 2
lm de alcool Temperature equivalence in degrees Celsius and degrees Fahrenhe.it/
Echivalenla temperaturii in grade Celsius Si grde Falvenheit
hnl x volum consumat) : 1000 :
r$ Cdsius (oC) Fahrenheit (oF) Celsius ("C) Fahrenheit ('F)
t5 95 38,5 l0r.3
15,5 95.9 39 t42,2
5 96,8 39,5
llngime gi distan{i l 16.5 97.7 40
103,I
104
n 98.6 40,5 r04,9
imr (mm)
t7.5 99.5 4t 105,8
tirtru (cm,l s 100,4 42 t47,6
n (m)
ffiti de mtrsur[ incl utilizate in
lile atglofone;
-hh
- Pbior
-bd

Greutate
r (g)
cEn (kg)
ffiti de mtrsurl inc[ utilizate in
ftfl3r anglofone:
- Livre
- u6kg

Temperaturi
bd Celsius ("C)
tr pczent folosit in majoritatea 1trri-
q cu erceptia Statelor Unite Ei a
:nrmelor anglofone in vdrstd !

nd fahrenheit ("F)
 Pacient history Anamneza pacientului .

Miscellaneous Generalitefi
Hello, what is yourname? Bund ziua, cum vtr numili?
- Surname Nume
- First name (Christian name) - Prenume
How old are you ? Ce vdrsttr aveli ?

What brings you here today ? De ce ati venit azi la consultalie ?

Where do you feel the pain ? (show me Unde vd doare ? (ardtatri-mi cu mina)
with your hand)
Foint out in the table of contents the chap- Indicali in cuprins capitolul referitor la
ter related to your complaint. problema dumneavoastr[.

General health, Starea generale

How much do you weigh ? Ce greutate ave[i ?
I kg : 2.21lb I livrl = 0,45 kg
Your weight: Greutatea dumneavoastr[ :

- is it stable? - este stabiltr?

- has it increased ? - a crescut ?
- has it decreased: - a scdzut:
- by how many kilogrammes ? (See - cu cite kilograme ? (Vezi pagina 24)
page 24)
-
in how much time? (See page 2l) -in cdt timp? (Vezi pagina 2l)
Do you feel a lack of energy ? Vd simtiti lipsit de energie ?
Do you have any fever? Avetri febrd?
Since when ? De cdnd ?

3: iil #: il:il;tacks or shivering, ffiliH::;.,

How long have you been fasting ? De cit timp nu mdncatri ?
General deterioration Alterarea stdrii generale
28 Pacient history

Past medical history Istoricul personal

Have you ever been hospitalised ? A1i mai fost spitalizat ?
- Where ? (address) - Unde ? (adresa)
- When? - Cdnd ?
Have you had all the childhood diseases ? Atri avut toate bolile copiltrriei ? ,

Have you had any surgery ? Atri suferit vreo operafie ?

- When (time) ? - Cdnd ? (scrieli data)
- Which ones ?
- Ce fel?
- appendix - apendiciti
- tonsils - amigdale
- hernia - hernie
-tumour - fumord
-other (show me your scar) - altele (ardtagi-mi cicatricea)
Did you ever/do you have: Atri avut vreodat5/ave1i :
- high blood pressure (hypertension) ? - hipertensiune arteriali ?
- diabetes ? - diabet ?
- asthma ? - astm?
_ COPD? _ BPOC?
- sexually transmitted diseases ? - boli cu transmitere sexual[ ?
If you have this complaint for a few Daci avetri aceste probleme de mai multe
months now, why did you present today ? luni, de ce v-ati prezentat astdzi?
Has something changed ? S-a schimbat ceva ?

Drug history Tratamente urmate

Do you take arry: Luatri:
- prescribed medication ? - medicamente pe retetl ?
- over the counrer medication (OTC) ? - medicamente eliberate ftrrd retretd'l
Do you kuow their names ? $titri cum se numesc ?
What dose are you taking ? Ce dozl luali ?
How many times a day ? De cdte ori pe zi?
Do you have them with you ? Le aveli la dumneavoastri ?
Show me the medicine containers. Aritali-mi curiile de medicamente.
Can you show me a list or your last pre- imi putetri ardta o listtr a medicamentelor
scription ? 6urruleavoastrtr sau ultima reteti ?
 Anarnneqa pacientului 29

Istoricul personal Are you allergic to anything that you Din cite gti1i, suntetri alergic la ceva ?
tnow of?
ri fr6t spitalizar ? - aspirin - aspirintr
? (dresa) - penicillin - penlcllna
U? - gther antibiotics - alte antibiotice
it Etre bolile copiltrriei? - other medicine (write the name down) - alt medicament (scrieli denumirea) I

*rl vreo operalie? What happens when you take them ? Ce se intimpl[ c6nd le luali ?
I? (scriegi data) - anaphylaxis - $oe anafiIactic
b tr? - rash - erup1ie cutanati
- acndicitil - mouth swelling - umflarea gurii
- rlgdate difficulry breathing - dificult{i de respiralie
' htrb * choking sensation - senzatie de sufocare
-ffi - abdominal discomfort - durere abdominal5
- #e (artrtati-mi cicatricea) ,
No known drug allergies (NKDA) Nicio alergie cunoscurtr
ll vrcodatitr/ave1i :

irrmiune arterialtr ?
E" Family history Istoricul familial
l--
Foc? Are your parents alive ? Ptrrinlii dumneavoastrd sunt in viald ?
fr cu transmitere sexuald ? If not, at what age did they die? Dactr nu, la ce vdrsttr au decedat?
tqimte probleme de mai multe What was the cause of their death? Din ce cauzl au decedat?
, - oe v-a1i prezentat ast5;zi? - accident - accident
frbet ceta' - heart problem - probleme cardiace
- cancer * cancer
- infectious disease - boald infectrioasd
Tratamente urmate - hereditary disease - which one ? boaltr ereditartr : care ?
- other - altele
[: Do you have any: Aveli:
fuente pe regetd'l - brothers and sisters (siblings) ? - foati Si surori?
nfumte eliberate fdr[ retretd? - children? - copii ?
Gn s numesc? - How many? - Ceti?
H hrti? - Age? - Ce vdrsttr au ?
*ai pea? Are they in good health ? Sunt slnltoEi?
Efi h drmneavoastrd ?
li-ri Giiih de medicamente.
rllr o listtr a medicamenrelor
-fi
ffi sau ultima reletd'l